Jeff Chervenak

Ready to start on the road to recovery?

Please fill out and submit this form, and we can begin your healing journey


History

Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?
Are you currently taking any prescription medication?
Have you ever been prescribed psychiatric medication?
Have you ever suffered any traumatic physical injury, e.g. accidents or significant injuries from sport or recreational activities?
Have you ever suffered any emotional trauma that you believe I should know about, even if you’re not willing or ready to discuss it?

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